Credentialing Specialist

4 weeks ago

Coral Gables, Florida, United States DOCTORS HEALTHCARE PLANS, INC. Full time
Job Summary:

We are seeking a highly organized and detail-oriented Credentialing Specialist to join our team at Doctors HealthCare Plans, Inc. The successful candidate will be responsible for maintaining an efficient provider credentials system, ensuring completed credentials CAQH profiles and/or applications are received and processed, and providing data entry and clerical support to the Credentialing Department.

Key Responsibilities:
  • Process practitioner credentialing and recredentialing application packets, including reviewing each application for completeness and requesting missing data from practitioner offices and/or Contracting Department staff.
  • Create new electronic records in the credentialing database and perform data entry of all Initial (new) and Reappointment (recredential) Practitioners credentials applications.
  • Request State licenses, Drug Enforcement Agency (DEA) certificates, Liability insurance, National Practitioner Database (NPDB) Report, Office of Inspector General (OIG) reports, Board certification, School/Residency/Fellowship completion, Hospital privileges verification, System Award Management (SAM), Claims history, Accreditation (ancillary facilities), Site Visits, and obtain additional information or clarification from practitioner offices as needed.
  • Process practitioner recredentialing applications within 3 years of initial credentialing date.
  • Maintain delegated entities' files, submitted documents, and perform data changes, including State licenses, DEA certificates, Liability insurance, NPDB report, OIG reports, SAM report, Board certification, Hospital privileges verification, claims history, Accreditation (ancillary facilities), and obtaining additional information or clarification from practitioner offices as needed.
  • Assist the Credentialing Director or designee with various tasks, as needed.
  • Receive, sort, and distribute incoming mail and faxes as needed.
  • Maintain thorough operational knowledge of the DHCP Credentialing CACTUS Database and Credentialing Policies & Procedures.
  • Provide input into updating Credentialing Procedures annually.
Requirements:
  • Minimum of two (2) years previous experience in a managed care organization's Credentialing department.
  • NAMSS CPCS certification is preferred, or a commitment to pursue certification within two years.
  • Knowledge of basic medical terminology.
  • Ability to analyze data and make appropriate decisions.
  • Ability to work as a team under stressful conditions.
  • Good verbal communication skills.
  • Bilingual English and Spanish - (preferred but not required).
  • Excellent organizational skills.
  • Extremely detail-oriented.
  • Ability to maintain confidentiality.
  • Minimum typing skills of 45 WPM.
  • PC proficiency and Windows-based software knowledge (Microsoft Word, Excel, Outlook) required.
Our Company:

Doctors HealthCare Plans, Inc. is committed to creating a diverse environment. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status. DFWP

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